The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart.
What action should the nurse take?
Document findings
Determine whether the patient can count fingers
Obtain a tumbling E chart to assess visual acuity
Complete an internal eye exam .
The Correct Answer is B
Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen
chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.
Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.
Correct Answer is A
Explanation
Choice A rationale
Myasthenia gravis is a neuromuscular disorder characterized by weakness and fatigue of voluntary muscles. Edrophonium is a medication that is used in the diagnosis and treatment of myasthenia gravis. It works by inhibiting the breakdown of acetylcholine, a neurotransmitter that transmits signals in the nervous system, thereby improving muscle strength.
Choice B rationale
Myasthenia gravis is not a disorder of motor and sensory dysfunction. It primarily affects the neuromuscular junction, leading to muscle weakness and fatigue. Sensory function is typically not affected in myasthenia gravis.
Choice C rationale
This statement is correct in that myasthenia gravis does not cause sensory impairment. However, it does not indicate an understanding of the disease as a whole, as it does not address the primary symptom of muscle weakness.
Choice D rationale
Myasthenia gravis does cause progressive muscle weakness, but it does not cause sensory deficits. Therefore, this statement indicates a partial understanding of the disease.
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